Affidavit And Application For Class I Temporary Permit Form printable pdf download

Affidavit And Application For Class I Temporary Permit Form

AFFIDAVIT AND APPLICATION FOR CLASS I TEMPORARY PERMIT

I. APPLICANT: Name ________________________________________

(Nonprofit civic or charitable organization)

Address: _____________________________________________

(street or post office box)

(city)

(state)

(zip)

Person responsible for event: ___________________________

Telephone number: ______________________________

II. EVENT: __________________________________________________

(type of event)

Date: ________________________________________________

(month)

(day)

(year)

Hours of event:

__________

_____________

(beginning)

(ending)

Location: _______________________________________________

(actual location)

Address: _______________________________________________

(street)

(city)

(zip)

Location is _

inside _

outside

the corporate city limits?

III. LIST THE PACKAGE STORE OR STORES FROM WHICH THE

ALCOHOLIC BEVERAGES USED IN THIS EVENT WILL BE

PURCHASED.

Business Name: ________________________________________

Address: ______________________________________________

(street)

(city)

(zip)

IV. Has any officer or director of the organization ever been convicted of

any of the following: a felony in any state or federal court OR violation

of the "Local Option Alcoholic Beverage Control Laws" of the State of

Mississippi OR violation of any law relating to alcoholic beverages,

beer or light wine? ___________________

If "yes", explain fully: ______________________________________

____________________________________________________________

Affidavit And Application For Class I Temporary Permit Form

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